Cause-effect diagrams

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1 A pragmatic way of doing root-cause analysis Version: 1.1 ( ) Teams not businessoriented Teams grouped by component Teams not focused Team not getting feedback from customer Lack of team spirit Teams don t have own PO Ineffective requirements communication Too much focus on written specs POdoesn t have own team Unclear roles & responsibilities Lack of discipline in teams Feature split across multiple teams Hard to plan Delayed releases Lack of transparancy No burndowns Fear of committing Bad throughput in development s estimating Not measuring velocity Cutting quality instead of scope Difficult to release Teams disrupted during sprint Many defects Lack of test automation Hard to change the code Many operational problems Customers dissatisfied Purpose of this article... 2 Solve problems, not symptoms... 3 A3 thinking - the Lean problem solving approach... 4 How to use cause-effect diagrams... 5 Example 1: Long release cycle... 6 Example 2: Defects released to production Example 3: Lack of pair programming Example 4: Lots of problems Practical issues how to create & maintain the diagrams Pitfalls Summary: Why to use cause-effect diagrams... 18

2 Purpose of this article Cause-effect diagrams are a simple and pragmatic way of doing root cause analysis. I ve been using these diagrams for years to help organizations understand and solve all kinds of problems technical as well as organizational. The purpose of this article is to show you how cause-effect diagrams work, so you can put them to use in your own context. Acknowledgements I d like to thank Tom Poppendieck for encouraging me to write about this, and for keeping my reading list constantly stocked with interesting books and articles about Lean and Systems thinking. page 2 / 18

3 Solve problems, not symptoms The key to effective problem solving is to first make sure you understand the problem that you are trying to solve - why it needs to be solved, how you will know when you ve solved it, and what the root cause is. Often symptoms show up in one place while the actual cause of the problem is somewhere completely different. If you just solve the symptom without digging deeper it is highly likely that problem will just reappear later in a different shape. : Smoke in my bedroom. Bad solution: Open the window and go back to sleep. Good solution: Find the source of the smoke and solve it. Whoops, there s a fire in the basement! Extinguish it, find out what caused the fire in the first place, install a fire alarm for earlier warning next time. : Hot forehead, tired. Bad solution: Put ice on forehead to cool it down. Eat some sugar to wake up. Keep working. Good solution: Take my temperature. Oh, I have fever! Go home and rest. : Memory leak in server. Bad solution: Buy more memory. Good solution: Find & fix the source of the memory leak. Implement tests to detect new memory leaks in the future. : Water in the boat. Bad solution: Pump out the water & keep sailing. Good solution: Find the source of the water. Ah, a hole! Fix it. Then pump out the water.... and so on. Most problems in organizations are systemic. The system (your organization) has a glitch that needs to be fixed. Until you find the source of the glitch, most attempts to fix the problem will be futile or even counterproductive. page 3 / 18

4 A3 thinking - the Lean problem solving approach One of the core tenets of Lean Thinking is Kaizen continuous process improvement. Toyota, one of the most successful companies in the world, attributes much of their success to their highly disciplined problem solving approach. This approach is sometimes called A3 thinking (based on the single A3-size papers used to capture knowledge from each problem solving effort). Here s an example & template: With the A3 approach, a significant amount of time (the left half of the sheet) is spent analyzing and visualizing the root cause of a problem before proposing solutions. A cause-effect diagram is only one way of doing a root-cause analysis. There are other ways too, such as value stream maps and Ishikawa (fishbone) diagrams. The sample A3 above contains a value stream map (top left) and a cause-effect diagram (bottom-left). The nice thing about cause-effect diagrams is that they are fairly intuitive and self-explanatory (especially compared to fishbone diagrams). Another advantage is that you can illustrate reinforcing loops (vicious cycles), which is very useful from a systems thinking perspective. The rest of this article describes how to effectively create and use these diagrams. page 4 / 18

5 How to use cause-effect diagrams Here s the basic process: 1. Select a problem anything that s bothering you - and write it down. 2. Trace upwards to figure out the business consequences, the visible damage that your problem is causing. 3. Trace downwards to find the root cause (or causes). 4. Identify and highlight vicious cycles (circular paths) 5. Iterate the above steps a few times to refine and clarify your diagram 6. Decide which root causes to address and how (i.e. which countermeasures to implement) Later on, follow up. If your countermeasures work, then congratulations! If your countermeasures didn t work, then don t despair. Analyze why it didn t work, update your diagram based on the new knowledge gained, and try some other countermeasures. So a countermeasure is in fact an experiment, not a solution. Your hypothesis is that this countermeasure will solve (or mitigate) the problem, but you can never be sure. You are in effect prodding your system to see how it reacts. That s why the follow-up is important. Failure really just means that your system is trying to tell you something so you d better listen. The only real failure is the failure to learn from failure! page 5 / 18

6 Example 1: Long release cycle Let s say our problem is that we always miss deadlines. More specifically, our releases always occur at a later date than planned. Delayed releases A problem is only a problem if it conflicts with your goal. So start by defining your goal, and think about the consequences of this problem in terms of your goal. This can be done by asking a series of so what? questions until you identify the visible damage. Let s say our goal is to delight our customers and maximize our revenue. Our dialog might sound something like this: Q: Who cares if the releases are delayed? What is the consequence? A: Delays make our release cycles long Q: So what? A: That delays our revenues, which messes up our cash flow. It also causes us to lose customers, since they are impatient and don t like waiting longer than necessary. As we talk, we add boxes and cause-effect arrows to the diagram. Normally I try to go upwards from the original problem statement when mapping out consequences, but that isn t a strict rule. Delayed revenue Loss of customers Long release cycle Delayed releases So delayed releases isn t really the problem. The real problem is delayed revenue and loss of customers. At this point we should consider three things: 1. Are there any other issues that are causing loss of customers or delayed revenues? If so, are delayed releases the biggest culprit or should we turn our attention elsewhere? 2. Can we quantify the problem? How much revenue have we lost? How many customers have we lost? This data will help us evaluate how much effort it is worth spending to solve this problem. 3. How will we know when we ve solved the problem? If a consultant comes in, does a noisy rain dance and then proudly proclaims says I ve solved the problem now, how will we call the bluff? page 6 / 18

7 Once we ve spent some time analyzing the consequences of the problem it is time to dig downwards towards the root. This is done by asking a series of why questions. Yes, this is the five whys technique that you ve probably heard of if you ve studied lean thinking. Q: Why are the releases delayed? A: Because the scope keeps increasing Q: Why? A: Because the customers comes up with new features and insists that we add them to the current release, and refuses to allow us to remove lower priority features. Q: Why? Why not defer the features until next release? A: Because the release cycle is so long, so new demands appear before the release is done. OK, that was only 3 whys. But you get the picture. This dialog gives us the following picture: Delayed revenue Loss of customers Long release cycle Business needs change within current release cycle Delayed releases Total scope increase New features added to current release Lower priority features not removed The vicious cycle (or re-enforcing loop) is highlighted with red arrows. Recurring problems almost always involve loops like this, but they may take some time to find. Spotting these will greatly increase your likelihood of solving the problem effectively and permanently! page 7 / 18

8 Our goal is to identify the root cause(s) of this problem, so we can achieve maximum effect with minimum effort. It is easy to miss important causes on the first pass so go back and ask a few more whys. Q: Why is the release cycle long? Are delayed releases the only cause? A: Well actually, even without the delays our planned release cycles are quite long. Q: How long is your planned release cycle? A: Once per quarter. Q: Why so long then? A: Because releases are expensive and complicated. Q: Why? A: Because there s so much stuff in each release, and because it s all manual work. Delayed revenue Loss of customers Difficult release process Lots of stuff in each release Release seldom Long release cycle Delayed releases Business needs change within current release cycle High fixed cost per release Total scope increase New features added to current release Lack of release automation Lower priority features not removed Look to the left, another vicious cycle (red arrows)! Long time between releases means lots of stuff in each release, which means releases are difficult and expensive, which makes us reluctant to have frequent releases. As you see, I ve decided to label two root causes. Now it s time to propose countermeasures: Lack of release automation Lower priority features not removed Countermeasure Implement release automation Negotiate a rule with the customer, allowing them to add new features to a release only if they remove lower priority features of corresponding size. page 8 / 18

9 There s no strict rule for determining which issue is the root cause, but here are some indicators. This issue has only arrows going out, and no arrows coming in. It doesn t feel meaningful to dig further down (ask further why questions) from here. This issue is something we can address, and it will probably have a significantly positive effect on the problem. The five whys technique is called so because it typically takes about five why questions to get to the root. We tend to stop asking too early, so keep digging! Note that the originally identified problem delayed releases wasn t really a problem or a root cause. It was just a symptom. We used that as a handle to dig upwards to identify the real problem, and then downwards to identify the root causes. This allows us to propose effective countermeasures in an informed way. Without this type of analysis, we tend to jump to conclusions and execute ineffective and counterproductive changes. For example adding more people, even though head count had nothing to do with the problem. Or changing the incentive model (reward people for releasing on time or punish people for releasing late) even though the current incentive model had nothing to do with the problem. I bet you ve already seen that happen a few times. page 9 / 18

10 Example 2: Defects released to production Let s say we are having problems with defective code being released to production. Defects release to production Q: So what? A: The defects make our customers angry Angry customers Defects release to production Q: Why are defects released to production? A: Because they aren t properly tested before release. Q: Why not? (etc) Here s where we ended up: Angry customers Defects release to production Hotfixes required Releases not properly tested Teams disrupted Lack of test automation Stress Lack of tools & training in test automation Not enough time to write test scripts Scope of sprint not reduced Look at that, two reinforcing loops! Check out the red arrows. page 10 / 18

11 Loop 1 (inner loop): Defects in product causes hot-fixes, which disrupts the team. Since they aren t allowed to reduce scope, they are stressed and don t have time to test new releases properly. Which, of course, leads to more defects in production. Loop 2 (outer loop): Because they are stressed, they don t have time to write automated test scripts either. This leads to an overall lack of test automation, making it harder and harder to regression-test new releases properly, which leads to defects in production and hot-fixes and ultimately more stress. But wait, there s more! Teams hate being disrupted. This disturbs flow and, in the long run, ruins motivation. This might explain which the staff turnover rate has been high! So in solving the original problem (defects in production) we get the added bonus of reducing team turnover! Angry customers Loss of team members Defects release to production Hotfixes required Releases not properly tested Teams disrupted Teams demotivated Lack of test automation Stress Lack of tools & training in test automation Not enough time to write test scripts Scope of sprint not reduced That s the nice thing about addressing the root cause. s are usually the cause of more than one problem (that s why they are called root...). page 11 / 18

12 Example 3: Lack of pair programming I was asked to help a client figure out why they weren t doing XP practices like pair programming and test-driven development. We know that we should be doing it, but we aren t. No TDD No pair programming So is lack of TDD and pair programming really a problem? As usual, the things we call problems often turn out to be just symptoms. Q: What is the consequence of not doing pair programming and TDD? A: We think we would have much better code quality if we did these things. Q: What is the consequence of bad code quality? Have you encountered any actual problems due to bad code quality? A: Yeah, we ve had some crashing demos. We are a research company and demos are how we get business, so this is really a problem. Crashing demos Bad code quality (etc) (etc) (etc) No TDD No pair programming OK, let s take one of the issues and see if we can dig down to the root. Q: Why aren t you pair programming then? A: Because many people are afraid that it won t work, and that we will be wasting our time. We have no proof that it works. Q: What kind of proof would you need? A: Well, we ve seen studies that indicate that it works. But nobody here has really tried it, so we aren t sure that it works. Well, there s the first loop: No pair programming No proof that pair programming works No experience of pair programming page 12 / 18

13 They don t want to do it because they don t know that it will work. And they don t know that it will work because they haven t tried it... Q: Why haven t you at least given pair programming a try? A: We don t have time to experiment. Q: Why not? A: Because we don t have any slack. Each hour is accounted for. Our customers keep piling work on us. Q: Why don t they let you manage your own time, and let you pull in more work whenever you are ready? A: They don t trust us to use our time effectively. The lack of trust also leads to a general fear of failure, which of courses reduces the likelihood that they will try something new like pair programming without proof that it works. No pair programming Fear of failure No proof that pair programming works No experience of pair programming No time to experiment No slack Push-scheduling instead of pull Each hour must be debitable Lack of trust So there appears to be two big root causes: Lack of trust, and the management principle that every hour must be debitable. Let s fold this back into the big picture. page 13 / 18

14 Crashing demos Bad code quality (etc) (etc) (etc) No TDD No pair programming Lack of trust Lack of trust turned out to be the root cause of not doing XP practices such as TDD and pair programming. That causes bad quality which causes crashing demos. And guess what? Crashing demos reduce trust even further. There s a vicious circle for you! The interesting thing is that we did this in a 2-day workshop with about 25 people. At the beginning we were talking mostly about technical stuff how to get started with TDD and pair programming. That didn t really get us anywhere, so we instead split into groups and had each group choose one problem and start drawing cause-effect diagrams and create problem solving A3s. The interesting thing is that several of the groups that were analyzing seemingly different problems came up with the same root cause lack of trust! The diagram above was just one example of this. So by the end of the day we were all talking about what we could do to increase the level of trust between the customer and the developers, which was a surprising turn of events. For starters we agreed that we should invite them (the customers) to participate next time we do this type of workshop, which should lessen the use of terms like us and them... page 14 / 18

15 Example 4: Lots of problems Here s a bigger example. This organization was doing Scrum but was having some problems. After some interviews and workshops the cause-effect diagram that emerged showed that they weren t really doing Scrum correctly and that this was causing problems. = fix first = root cause = visible damage = talked about = not talked about = vicious cycle Teams not businessoriented Teams grouped by component Teams not focused Team not getting feedback from customer Lack of team spirit Teams don t have own PO Ineffective requirements communication Too much focus on written specs POdoesn t have own team Unclear roles & responsibilities Lack of discipline in teams Feature split across multiple teams Hard to plan Delayed releases Lack of transparancy No burndowns Fear of committing Bad throughput in development s estimating Not measuring velocity Cutting quality instead of scope Difficult to release Teams disrupted during sprint Many defects Lack of test automation Hard to change the code Many operational problems Customers dissatisfied It became clear to everyone that many of the root causes would be addressed with a proper Scrum implementation (for example reorganizing into cross functional teams, and making sure each team has a dedicated product owner). This triggered organizational changes that ultimately fixed many of the root causes (green stars). The next step was to improve test automation. Scrum isn t always the solution of course. In fact, sometimes Scrum itself is the problem and other techniques such as Kanban are the solution See my upcoming book Kanban and Scrum making the most of both for more on that. page 15 / 18

16 Practical issues how to create & maintain the diagrams Working alone When creating the diagrams alone I find it easiest to work directly with a diagramming tool such as Visio or Powerpoint. It s nice to be able to move things around quickly, resize the boxes, and make quick backups when playing around with the picture. Working in a small group (2 8 people) Gather in front of a whiteboard or flipchart. Use stickynotes for issues, and draw arrows to connect them. Whiteboard is preferable, so you could erase and redraw the arrows as you move the stickynotes around. Make sure everybody is helping out, not just one person doing all the drawing. Make sure someone takes a high-resolution photo and sends to everyone after the meeting. Working in a larger group (9 30 people) Split the group into smaller teams, each focused around one specific problem. It is OK to have multiple teams working independently on the same problem they may come to the same conclusion or different conclusions, and both cases are interesting. Each team works with a flipchart/whiteboard and stickynotes. Gather everyone together at regular intervals to share insights. Long-term maintenance of a diagram Let the diagram live in a tool such as Visio or Powerpoint. Whenever you get to a workshop setting, decide if the meeting is mostly for presenting the diagram, or for updating it. If presenting, use a projector to show the diagram directly in Visio (or whatever tool you use). If updating the picture, replicate it on a whiteboard/flipchart with stickynotes and arrows so that people can collaborate effectively. Then synchronize with the electronic tool after the meeting. This type of synchronizing does take some time, but it is often worth it. Nothing can beat physical tools like whiteboards & stickynotes when doing team workshops. page 16 / 18

17 Pitfalls Too many arrows and boxes Sometimes the diagram gets too messy to be readable. In that case you need to simplify it. Here are some techniques: Remove redundant boxes (i.e. boxes that don t add much value to the diagram). Focus on depth first rather than breadth first. Don t write all causes of a problem, write only the most important one or two, and then keep digging deeper. Accept imperfections, a diagram like this will never be perfect. All models are wrong, but some are useful (George Box) Maybe your problem area is too broad, try to limit yourself to a more narrowly defined problem. Split the diagram into pieces, like I did in example 3 above. Oversimplification This type of cause-effect diagram is simple, intentionally so. It doesn t replace face-to-face communication. If you need something more advanced or formally defined read a book on systems thinking, such as The Fifth Discipline by Peter Senge. There are ways to distinguish between reinforcing loops and balancing loops, and ways of adding a temporal dimension (showing how X causes Y but with a delay). Just beware even a perfect diagram is pretty useless if you need a doctor s degree to understand it. Getting personal Avoid blame game issues such as: Lots of defects in Jeff s code Jeff is lazy & clumsy solving works best if you assume that all problems are systemic. Sure there are clumsy people. But even if that is causing us significant problems then that is still a systemic problem we have a system that assumes clumsy people aren t clumsy, or a system that lets extremely clumsy people in, or a system that doesn t help clumsy people get less clumsy, etc. This point is worth emphasizing: Treat all problems as systemic! page 17 / 18

18 Summary: Why to use cause-effect diagrams Create a common understanding o Team-based problem is extremely effective, but requires a common understanding of the problem. Cause-effect diagrams are a very practical collaboration technique. Identify how problems affect the business o So that you can focus on the most important problems first and make informed decisions. Find root causes o So that you can maximize the effect of your changes. Find vicious cycles (negative reinforcing loops) o So that you can break them, or turn them into positive reinforcing loops (good stuff leading to more good stuff, instead of bad stuff leading to more bad stuff). Good luck! /Henrik henrik.kniberg AT crisp.se Web: Blog: page 18 / 18

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